SB70-AA3,50,63 (f) Nothing in this subsection or rules promulgated under this subsection
4prohibits a disability insurance policy or a self-insured health plan from providing
5benefits in excess of the essential health benefit coverage required under this
6subsection.
SB70-AA3,50,87 (g) This subsection does not apply to any disability insurance policy that is
8described in s. 632.745 (11) (b) 1. to 12.
SB70-AA3,32 9Section 32. 632.895 (16m) (b) of the statutes is amended to read:
SB70-AA3,50,1410 632.895 (16m) (b) The coverage required under this subsection may be subject
11to any limitations, or exclusions , or cost-sharing provisions that apply generally
12under the disability insurance policy or self-insured health plan. The coverage
13required under this subsection may not be subject to any deductibles, copayments,
14or coinsurance.
SB70-AA3,33 15Section 33. 632.895 (17) (b) 2. of the statutes is amended to read:
SB70-AA3,50,2016 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and
17medical services that are necessary to prescribe, administer, maintain, or remove a
18contraceptive, if covered for any other drug benefits under the policy or plan
19sterilization procedures, and patient education and counseling for all females with
20reproductive capacity
.
SB70-AA3,34 21Section 34. 632.895 (17) (c) of the statutes is amended to read:
SB70-AA3,51,1122 632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions,
23and limitations, or cost-sharing provisions that apply generally to the coverage of
24outpatient health care services, preventive treatments and services, or prescription
25drugs and devices that is provided under the policy or self-insured health plan. A

1disability insurance policy or self-insured health plan may not apply a deductible or
2impose a copayment or coinsurance to at least one of each type of contraceptive
3method approved by the federal food and drug administration for which coverage is
4required under this subsection. The disability insurance policy or self-insured
5health plan may apply reasonable medical management to a method of contraception
6to limit coverage under this subsection that is provided without being subject to a
7deductible, copayment, or coinsurance to prescription drugs without a brand name.
8The disability insurance policy or self-insured health plan may apply a deductible
9or impose a copayment or coinsurance for coverage of a contraceptive that is
10prescribed for a medical need if the services for the medical need would otherwise be
11subject to a deductible, copayment, or coinsurance.
SB70-AA3,35 12Section 35. 632.897 (11) (a) of the statutes is amended to read:
SB70-AA3,51,2113 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may
14promulgate rules establishing standards requiring insurers to provide continuation
15of coverage for any individual covered at any time under a group policy who is a
16terminated insured or an eligible individual under any federal program that
17provides for a federal premium subsidy for individuals covered under continuation
18of coverage under a group policy, including rules governing election or extension of
19election periods, notice, rates, premiums, premium payment, application of
20preexisting condition exclusions,
election of alternative coverage, and status as an
21eligible individual, as defined in s. 149.10 (2t), 2011 stats.
SB70-AA3,9323 22Section 9323. Initial applicability; Insurance.
SB70-AA3,51,2423 (1u) Coverage of individuals with preexisting conditions, essential health
24benefits, and preventive services.
SB70-AA3,52,7
1(a) For policies and plans containing provisions inconsistent with these
2sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e),
3(3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac)
41. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c),
5and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies
6to policy or plan years beginning on January 1 of the year following the year in which
7this paragraph takes effect, except as provided in par. (b).
SB70-AA3,52,158 (b) For policies and plans that are affected by a collective bargaining agreement
9containing provisions inconsistent with these sections, the treatment of ss. 632.728,
10632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8)
11(a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8)
12(d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17)
13(b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on
14the effective date of this paragraph or on the day on which the collective bargaining
15agreement is entered into, extended, modified, or renewed, whichever is later.
SB70-AA3,9423 16Section 9423. Effective dates; Insurance.
SB70-AA3,52,2317 (1v) Coverage of individuals with preexisting conditions, essential health
18benefits, and preventive services.
The treatment of ss. 632.728, 632.746 (1) (a) and
19(b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748
20(2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1.
21i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897
22(11) (a) and Section 9323 (1u) of this act take effect on the first day of the 4th month
23beginning after publication.”.
SB70-AA3,52,24 24180. Page 374, line 11: after that line insert:
SB70-AA3,53,1
1 Section 36. 609.20 (3) of the statutes is created to read:
SB70-AA3,53,82 609.20 (3) The commissioner may promulgate rules to establish minimum
3network time and distance standards and minimum network wait-time standards
4for defined network plans and preferred provider plans. In promulgating rules
5under this subsection, the commissioner shall consider standards adopted by the
6federal centers for medicare and medicaid services for qualified health plans, as
7defined in 42 USC 18021 (a), that are offered through the federal health insurance
8exchange established pursuant to 42 USC 18041 (c).”.
SB70-AA3,53,9 9181. Page 374, line 11: after that line insert:
SB70-AA3,53,10 10 Section 37. 609.045 of the statutes is created to read:
SB70-AA3,53,12 11609.045 Balance billing; emergency medical services. (1) Definitions.
12In this section:
SB70-AA3,53,1313 (a) “Emergency medical condition” means all of the following:
SB70-AA3,53,1714 1. A medical condition, including a mental health condition or substance use
15disorder condition, manifesting itself by acute symptoms of sufficient severity,
16including severe pain, such that the absence of immediate medical attention could
17reasonably be expected to result in any of the following:
SB70-AA3,53,1918 a. Placing the health of the individual or, with respect to a pregnant woman,
19the health of the woman or her unborn child, in serious jeopardy.
SB70-AA3,53,2020 b. Serious impairment of bodily function.
SB70-AA3,53,2121 c. Serious dysfunction of any bodily organ or part.
SB70-AA3,54,222 2. With respect to a pregnant woman who is having contractions, a medical
23condition for which there is inadequate time to safely transfer the pregnant woman

1to another hospital before delivery or for which the transfer may pose a threat to the
2health or safety of the pregnant woman or the unborn child.
SB70-AA3,54,53 (b) “Emergency medical services,” with respect to an emergency medical
4condition, has the meaning given for “emergency services” in 42 USC 300gg-111 (a)
5(3) (C).
SB70-AA3,54,76 (c) “Independent freestanding emergency department" has the meaning given
7in 42 USC 300gg-111 (a) (3) (D).
SB70-AA3,54,98 (d) “Out-of-network rate” has the meaning given by the commissioner by rule
9or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (K).
SB70-AA3,54,1310 (e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any
11preferred provider plan, as defined in s. 609.01 (4), that has a network of
12participating providers and imposes on enrollees different requirements for using
13providers that are not participating providers.
SB70-AA3,54,1514 (f) “Recognized amount” has the meaning given by the commissioner by rule
15or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H).
SB70-AA3,54,1916 (g) “Self-insured governmental plan” means a self-insured health plan of the
17state or a county, city, village, town, or school district that has a network of
18participating providers and imposes on enrollees in the self-insured health plan
19different requirements for using providers that are not participating providers.
SB70-AA3,54,2220 (h) “Terminated” means the expiration or nonrenewal of a contract.
21“Terminated” does not include a termination of a contract for failure to meet
22applicable quality standards or for fraud.
SB70-AA3,55,2 23(2) Emergency medical services. A defined network plan, preferred provider
24plan, or self-insured governmental plan that covers any benefits or services provided
25in an emergency department of a hospital or emergency medical services provided

1in an independent freestanding emergency department shall cover emergency
2medical services in accordance with all of the following:
SB70-AA3,55,33 (a) The plan may not require a prior authorization determination.
SB70-AA3,55,64 (b) The plan may not deny coverage on the basis of whether or not the health
5care provider providing the services is a participating provider or participating
6emergency facility.
SB70-AA3,55,97 (c) If the emergency medical services are provided to an enrollee by a provider
8or in a facility that is not a participating provider or participating facility, the plan
9complies with all of the following:
SB70-AA3,55,1310 1. The emergency medical services are covered without imposing on an enrollee
11a requirement for prior authorization or any coverage limitation that is more
12restrictive than requirements or limitations that apply to emergency medical
13services provided by participating providers or in participating facilities.
SB70-AA3,55,1714 2. Any cost-sharing requirement imposed on an enrollee for the emergency
15medical services is no greater than the requirements that would apply if the
16emergency medical services were provided by a participating provider or in a
17participating facility.
SB70-AA3,55,2218 3. Any cost-sharing amount imposed on an enrollee for the emergency medical
19services is calculated as if the total amount that would have been charged for the
20emergency medical services if provided by a participating provider or in a
21participating facility is equal to the recognized amount for such services, plan or
22coverage, and year.
SB70-AA3,55,2323 4. The plan does all of the following:
SB70-AA3,56,3
1a. No later than 30 days after the participating provider or participating facility
2transmits to the plan the bill for emergency medical services, sends to the provider
3or facility an initial payment or a notice of denial of payment.
SB70-AA3,56,64 b. Pays to the participating provider or participating facility a total amount
5that, incorporating any initial payment under subd. 4. a., is equal to the amount by
6which the out-of-network rate exceeds the cost-sharing amount.
SB70-AA3,56,117 5. The plan counts any cost-sharing payment made by the enrollee for the
8emergency medical services toward any in-network deductible or out-of-pocket
9maximum applied by the plan in the same manner as if the cost-sharing payment
10was made for emergency medical services provided by a participating provider or in
11a participating facility.
SB70-AA3,56,17 12(3) Nonparticipating provider in participating facility. For items or services
13other than emergency medical services that are provided to an enrollee of a defined
14network plan, preferred provider plan, or self-insured governmental plan by a
15provider who is not a participating provider but who is providing services at a
16participating facility, the plan shall provide coverage for the item or service in
17accordance with all of the following:
SB70-AA3,56,2018 (a) The plan may not impose on an enrollee a cost-sharing requirement for the
19item or service that is greater than the cost-sharing requirement that would have
20been imposed if the item or service was provided by a participating provider.
SB70-AA3,56,2421 (b) Any cost-sharing amount imposed on an enrollee for the item or service is
22calculated as if the total amount that would have been charged for the item or service
23if provided by a participating provider is equal to the recognized amount for such
24item or service, plan or coverage, and year.
SB70-AA3,57,2
1(c) No later than 30 days after the provider transmits the bill for services, the
2plan shall send to the provider an initial payment or a notice of denial of payment.
SB70-AA3,57,63 (d) The plan shall make a total payment directly to the provider who provided
4the item or service to the enrollee that, added to any initial payment described under
5par. (c), is equal to the amount by which the out-of-network rate for the item or
6service exceeds the cost-sharing amount.
SB70-AA3,57,107 (e) The plan counts any cost-sharing payment made by the enrollee for the item
8or service toward any in-network deductible or out-of-pocket maximum applied by
9the plan in the same manner as if the cost-sharing payment was made for the item
10or service when provided by a participating provider.
SB70-AA3,57,16 11(4) Charging for services by nonparticipating provider; notice and consent.
12(a) Except as provided in par. (c), a provider of an item or service who is entitled to
13payment under sub. (3) may not bill or hold liable an enrollee for any amount for the
14item or service that is more than the cost-sharing amount calculated under sub. (3)
15(b) for the item or service unless the nonparticipating provider provides notice and
16obtains consent in accordance with all of the following:
SB70-AA3,57,1917 1. The notice states that the provider is not a participating provider in the
18enrollee's defined network plan, preferred provider plan, or self-insured
19governmental plan.
SB70-AA3,57,2320 2. The notice provides a good faith estimate of the amount that the
21nonparticipating provider may charge the enrollee for the item or service involved,
22including notification that the estimate does not constitute a contract with respect
23to the charges estimated for the item or service.
SB70-AA3,58,3
13. The notice includes a list of the participating providers at the participating
2facility who would be able to provide the item or service and notification that the
3enrollee may be referred to one of those participating providers.
SB70-AA3,58,64 4. The notice includes information about whether or not prior authorization or
5other care management limitations may be required before receiving an item or
6service at the participating facility.
SB70-AA3,58,87 5. The notice clearly states that consent is optional and that the patient may
8elect to seek care from an in-network provider.
SB70-AA3,58,99 6. The notice is worded in plain language.
SB70-AA3,58,1110 7. The notice is available in languages other than English. The commissioner
11shall identify languages for which the notice should be available.
SB70-AA3,58,1612 8. The enrollee provides consent to the nonparticipating provider to be treated
13by the nonparticipating provider, and the consent acknowledges that the enrollee
14has been informed that the charge paid by the enrollee may not meet a limitation that
15the enrollee's defined network plan, preferred provider plan, or self-insured
16governmental plan places on cost sharing, such as an in-network deductible.
SB70-AA3,58,1817 9. A signed copy of the consent described under subd. 8. is provided to the
18enrollee.
SB70-AA3,58,2019 (b) To be considered adequate, the notice and consent under par. (a) shall meet
20one of the following requirements, as applicable:
SB70-AA3,58,2421 1. If the enrollee makes an appointment for the item or service at least 72 hours
22before the day on which the item or service is to be provided, any notice under par.
23(a) shall be provided to the enrollee at least 72 hours before the day of the
24appointment at which the item or service is to be provided.
SB70-AA3,59,3
12. If the enrollee makes an appointment for the item or service less than 72
2hours before the day on which the item or service is to be provided, any notice under
3par. (a) shall be provided to the enrollee on the day that the appointment is made.
SB70-AA3,59,94 (c) A provider of an item or service who is entitled to payment under sub. (3)
5may not bill or hold liable an enrollee for any amount for an ancillary item or service
6that is more than the cost-sharing amount calculated under sub. (3) (b) for the item
7or service, whether or not provided by a physician or non-physician practitioner,
8unless the commissioner specifies by rule that the provider may balance bill for the
9ancillary item or service, if the item or service is any of the following:
SB70-AA3,59,1010 1. Related to an emergency medical service.
SB70-AA3,59,1111 2. Anesthesiology.
SB70-AA3,59,1212 3. Pathology.
SB70-AA3,59,1313 4. Radiology.
SB70-AA3,59,1414 5. Neonatology.
SB70-AA3,59,1615 6. An item or service provided by an assistant surgeon, hospitalist, or
16intensivist.
SB70-AA3,59,1717 7. A diagnostic service, including a radiology or laboratory service.
SB70-AA3,59,1918 8. An item or service provided by a specialty practitioner that the commissioner
19specifies by rule.
SB70-AA3,59,2220 9. An item or service provided by a nonparticipating provider when there is no
21participating provider who can furnish the item or service at the participating
22facility.
SB70-AA3,59,2523 (d) Any notice and consent provided under par. (a) may not extend to items or
24services furnished as a result of unforeseen, urgent medical needs that arise at the
25time the item or service is provided.
SB70-AA3,60,2
1(e) Any consent provided under par. (a) shall be retained by the provider for no
2less than 7 years.
SB70-AA3,60,12 3(5) Notice by provider or facility. Beginning no later than January 1, 2024,
4a health care provider or health care facility shall make available, including posting
5on a website, to enrollees in defined network plans, preferred provider plans, and
6self-insured governmental plans notice of the requirements on a provider or facility
7under sub. (4), of any other applicable state law requirements on the provider or
8facility with respect to charging an enrollee for an item or service if the provider or
9facility does not have a contractual relationship with the plan, and of information on
10contacting appropriate state or federal agencies in the event the enrollee believes the
11provider or facility violates any of the requirements under this section or other
12applicable law.
SB70-AA3,61,4 13(6) Negotiation; dispute resolution. A provider or facility that is entitled to
14receive an initial payment or notice of denial under sub. (2) (c) 4. a. or (3) (c) may
15initiate, within 30 days of receiving the initial payment or notice of denial, open
16negotiations with the defined network plan, preferred provider plan, or self-insured
17governmental plan to determine a payment amount for an emergency medical
18service or other item or service for a period that terminates 30 days after initiating
19open negotiations. If the open negotiation period under this subsection terminates
20without determination of a payment amount, the provider, facility, defined network
21plan, preferred provider plan, or self-insured governmental plan may initiate,
22within the 4 days beginning on the day after the open negotiation period ends, the
23independent dispute resolution process as specified by the commissioner. If the
24independent dispute resolution decision-maker determines the payment amount,
25the party to the independent dispute resolution process whose amount was not

1selected shall pay the fees for the independent dispute resolution. If the parties to
2the independent dispute resolution reach a settlement on the payment amount, the
3parties to the independent dispute resolution shall equally divide the payment for
4the fees for the independent dispute resolution.
SB70-AA3,61,5 5(7) Continuity of care. (a) In this subsection:
SB70-AA3,61,66 1. “Continuing care patient” means an individual who is any of the following:
SB70-AA3,61,87 a. Undergoing a course of treatment for a serious and complex condition from
8a provider or facility.
SB70-AA3,61,109 b. Undergoing a course of institutional or inpatient care from a provider or
10facility.
SB70-AA3,61,1211 c. Scheduled to undergo nonelective surgery, including receipt of postoperative
12care, from a provider or facility.
SB70-AA3,61,1413 d. Pregnant and undergoing a course of treatment for the pregnancy from a
14provider or facility.
SB70-AA3,61,1615 e. Terminally ill and receiving treatment for the illness from a provider or
16facility.
SB70-AA3,61,1717 2. “Serious and complex condition” means any of the following:
SB70-AA3,61,2018 a. In the case of an acute illness, a condition that is serious enough to require
19specialized medical treatment to avoid the reasonable possibility of death or
20permanent harm.
SB70-AA3,61,2321 b. In the case of a chronic illness or condition, a condition that is
22life-threatening, degenerative, potentially disabling, or congenital and requires
23specialized medical care over a prolonged period.
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